HNC Healthcare Practise Leah Bradley HNC Healthcare Practice Integrated Assignment.

Name: Leah Bradley Student Number: 30013528 Unit 2: Demonstrating professional principles and values in Health and Social Care Practice. Unit 3: Supporting the Individual Journey through integrated Health and Social Care. Unit 17: Effective Reporting and Record keeping in Health and Social Care. Unit Tutor: Nicola King, Ellen McCurdy, Roisin Wilson, Kate Kilfeather, Karen Roarty. Date of hand-in: 13/12/2021 Word count: 5070

HNC Healthcare Practise Leah Bradley Index Page: • • • • • • • • •

• • • • • • • • • • •

Introduction. How health care and social care are structured and delivered in Northern Ireland. These current unmet needs in Northern Ireland within health and social care services. The differences in the frameworks that are available to support integrated care in Northern Ireland. Evaluation of the services provided. The role of health and social care professionals supporting person centred care. Statutory, regulatory body and inspecting body requirements when recording and reporting information. The implications of non-compliance with these requirements. The impacts of non-compliance within the are setting in the references to; -The media -Service user safety -The credibility of the healthcare setting The process of storing records in the setting; -Paper based -Electronic based The current process used in chosen setting in order to store these; -Policies -Procedures Reasons that information is shared within a chosen setting. Evaluation of storing and sharing record process within the chosen healthcare setting. How technology is used in chosen setting. The responsibilities of sharing this information between multi-disciplinary team members. The purpose of reflection. Two models of rereflection. How reflective practice is applied into healthcare practice. How reflective practice is applied into health care race. The impact of your own professional and professional reflections and the impacts of the experiences of individual experiences using health services.

HNC Healthcare Practise Leah Bradley Introduction to handbook. I am a newly qualified nurse and work within a nursing home which is known as Summer-Hill. This setting has 34 service users who all have individual complex needs. I am a nurse within this nursing home and have been asked to create a handbook which will guide and assist student nurses who will have their placement within this setting. Within this handbook, the student nurse should examine the health, care and support services an individual requiring multidisciplinary care along with being able to assess the capacity of an individual to identify their needs. The student nurse handbook will also have description of the legal and regulatory aspects of reporting and record keeping within this care home. The role of reflection will also be discussed within a health and social care setting to show how it can impact development within this setting. I will complete documented risk assessments of individuals within this setting to determine appropriate care that this individual should receive. The risk assessments completed will demonstrate principles of recording, information recorded will be clearly documented, accurate and concise. I will also complete a reflection account which will evaluate and discuss my own knowledge and performance within this care home. In Northern Ireland, health and social care are delivered as a unified service. In Northern Ireland, a variety of organisations collaborate to plan, implement, and monitor health and social care. There are many organisations that work together throughout Northern Ireland to ensure that the individuals are receiving the best care according to their needs. Commissioning services, managing resources, and improving performance are all responsibilities of the Health and Social Care Board. Contracts for family health services supplied by GPs, dentists, opticians, and community pharmacists are also managed by the Board. These are all services that health and social care trusts do not provide. The regional Health and Social Care Board commissions trusts to offer health and social care services to the general population. In Northern Ireland, there are six health and social care trusts. Each Trust is in charge of its own personnel and services, as well as its own budget. The six of these health and social care trust are known as, Belfast Trust, Northern Trust, South Eastern Trust, Southern Trust, Western Trust and the NI Ambulance Trust. (Health and social care in Northern Ireland - Northern Health and Social Care Trust, 2021) Northern Ireland healthcare is provided through the NHS. The NHS is a health care system free to those living within this sector. The NHS is divided into Primary, which is the first point of care, for example, going to see the GP, going to see the dentist or speaking to a pharmacist, this is normally the first point of care. Secondary, which is normally when the individual attends the hospital, for example if the individual needs an operation or is attending a clinic such as a fracture clinic for breaking a bone. Tertiary care can be referred as “specialist care”. For example, this kind of care would include specialist surgeries such as neurosurgery, cardiothoracic surgery or other surgeries such as any kind of transplant. There are lot of unmet needs when it comes to health and social care services. These unmet needs are across many areas which include medication, physical health, sensory problems, emotional or mental health along with memory and social isolation. With the NHS being challengingly busy daily, there are multiple individuals

HNC Healthcare Practise Leah Bradley are ending up with unmet needs due to this. With GP’s not giving the individual enough time to explain what is going on or the GP not looking into this individuals issue in more detail. This can cause a misdiagnosis leadin g to the individual receiving incorrect medication, therefore the individual will be taking this medication, not noticing any difference with the issue they may be suffering; therefore, they are taking medication that is unnecessary. Unmet needs within physical health and mobility can cause a lot of issues for an individual, this can out them at higher risk of falls, accidents/incidents which the risk may have been reduced from happening if the needs were met and if they were receiving Physio therapy daily or having another individual with this individual ensuring that none of the falls, incidents or accidents take place and if they do, there is another individual there to help and call for help if more serious. An individual with unmet physical needs puts themselves at serious risk of falls whenever bathing is involved in case the individual does slip and fall, the individual may need help during mealtimes, they may need help getting in and out of the bathroom after using the toilet. Therefore, due to this it is important that the GP gets the individual on a referral list from primary care to secondary care due to their physical needs. Sensory needs can affect a range of individuals, from an individual with autism to an individual with dementia. Dementia results in a decreased ability to ensure needs are met when it comes to sensory as it is increasing difficulty in communicating needs. These needs can range from pain/health/physical and mental discomfort. This can then cause the individual to become disorientated, upset which may cause the individual to have a meltdown. There is not much a GP can do when it comes to individuals with dementia developing sensory problems as there is no cure for dementia, but they can give the individual a medication to ease the symptoms of dementia depending on how advanced it has gotten. Emotional and mental health have become seriously unmet within the NHS, this is when an individual has a mental health problem but doesn’t receive formal care or when the care is received, it tends to be insufficient or inadequate therefore it doesn’t help the individual which becomes an unmet need. For example, when an individual attends primary care such as their GP, they will speak to them about their mental health issues. The GP could offer to put the individual on a “waiting list” for counselling or they may offer a type of medication to try help the individual feeling the way they are feeling. The individual may decide to wait on the list for the counselling, but their mental health may deteriorate due to the waiting list or if the medication is taken, they may stop taking the medication due to the side effects they may be having/how they are left feeling. Therefore, due to this, emotional and mental health becomes an unmet need. Memory and social isolation can also fall under the same as emotional and mental health. Social isolation can cause an individual to develop anxiety, social anxiety and even depression. With social anxiety they may find it hard to talk to their GP about how they are feeling. This then also becomes an unmet need. Inspecting body requirements within health and social care settings happen to ensure that the healthcare services are meeting the required standards of care. This will include where good practise is identified and areas for improvement will be addressed. (Inspection and regulation of healthcare services, 2021). An example of this is the RQIA, which also funded by the government. It is important that record keeping is always kept within a setting like this. Record keeping within a place such

HNC Healthcare Practise Leah Bradley as the RQIA is essential and is important to keep track of how health and social care settings are keeping on top throughout their inspections. When inspections are done in health and social care settings, it is important that whatever notes/things need to be done are done as a member from the RQIA will come back and check to ensure that its done. If the health and social care settings don’t comply with the standards that the RQIA has left to be done they will be given a warning, if it still hasn’t the RQIA’s standards within the next visit the setting will have consequences and will be at risk of closure. Another framework available in Northern Ireland is NMC. This is also known as the Nursing and Midwifery Counsil. The NMC, will maintain a register for all nurses, midwifes and other specialist nurses/professionals which are eligible within the UK. Whilst working with the NMC it is important that the professionals within this follow all codes/guidelines. These are in place to keep the individuals working within this profession and individuals attending the services as safe as possible. It is important that the NMC implies record keeping when working within their health and social care, whether that may be within the hospital, GP practise or in the community such as a community carer. It is important that record keeping is always done when working with NMC as it can impact an individual’s life massively, for example, if an individual is given medication either within a hospital or by a nurse at home and it has not been recorded, they have no proof that this individual has been given the medication therefore puts them at risk of getting the medication given to them again which can cause the individual serious complications depending on the dosage and amount of medication given, therefore due to this, this can come across as non compliant as the individual that gave the medication did not record that the medication had been administered/given to meaning that they did not follow the code/guidelines lay out by the NMC. NISCC is another piece of framework within Northern Ireland. The Social Care Council's Standards of Conduct and Practice serve as the foundation for the social work and social care workforce's regulatory framework. They regulate the workforce by keeping a register and establishing standards for the behaviour, practise, and training of social workers, social work students, and social care professionals to guarantee that individuals who utilise services receive high -quality care. The Standards of Conduct and Practice establish the information and abilities necessary for competent practise and describe the beliefs, attitudes, and behaviours expected by registrants in their day-to-day work. They serve as a benchmark against which a registrant's actions and practises will be measured. The difference between these two pieces of framework is that the RQIA is an inspecting body, this is a requirement that will be done in every health ad social care setting. This ensures that the health and social care setting is meeting the correct standards of the RQIA to ensure all the individuals within/attending this setting is receiving the best care appropriate according to their need. RQIA will also give a warning if it isn’t up to their standards of care and will make a list on what needs done and they will revisit to ensure these checks have been made. If not, they will get one more chance and if they still haven’t met RQIA’s standards of care, they could be asked to shut down this health and social care setting. The difference between RQIA and NMC, the NMC is where all nurses and midwives have to register once they become a qualified midwife or nurse within the UK. It is in place to keep all the individuals registered under this, safe and professional while following the codes and guidelines that are in place which will also keep the service u sers safe. For example, by following the code and guidelines, the nurses and midwives will always

HNC Healthcare Practise Leah Bradley record any medication they’ve been given. This is extremely important as if it is not recorded, there is a chance the individual will be given the medication again as the service providers think it hasn’t been given so could possibly be given again. This can be fatal in some cases due to the dosage and the amount of medication given. There are many different types of record keeping. This can include recording i n their chart/file, or on an online database. Their chart/file will be locked away in a locked filing cabinet when not in use to ensure the individuals information is kept confidential, same for online database. It will be kept on a password protected computer where only the individual’s nurse/midwife can access which will also be kept confidential. This kind of information can only be shared on need-to-know-basis, meaning it can only be told to another service provider if an individual is at risk, either a risk to themselves or others. Another way an individual’s files can be shared is if multi-disciplinary care comes into place to provide person centred care. It is important that all doctors, nurses, physiotherapist, social worker, and anyone else that may be involved within the team, have access to this individual’s files/medical records. This is important to ensure that they can all work with the individual in a team to ensure that they provide the best appropriate care possible to give the individual the best chance. For example, if the individual has a stroke. They are taken into hospital to receive the best treatment plan suited to this individual needs. Therefore it is important that the doctor keeps checking on the individual on a regular basis to ensure that they are continuing to improve, the nurse to ensure they are comfortable, receiving correct medication at correct times, physiotherapist to help the individual get back on their feet, start by taking small steps at a time if possible depending on the severity of the stroke then the social worker, if the individual is fit to get back home eventually, they will make the adjustments to the individuals house, such as new stair railings or a stair lift if needed, possibility of door handles needing ch anged due to what side of the body the stroke effected most along with what kind of strength they’ve gotten back. If the social workers feel like the individual isn’t fit enough to live along or may need personal care at certain times of the day, there is a chance they may arrange carers. They may arrange them from a little as once a day to as much as 4 times a day depending on the individuals needs. If the social worker still feels like home isn’t the best option for this individual, they will talk and con sider the best options, this could be as much as placing the individual into a care home which also depends on the kind of needs the individual may need. It is important when working within this multi-disciplinary team that confidentiality, safety, and security is the main things within the team to ensure the individual is cared for and needs are met. It is important within this team and supporting person centred care that the individual will always have a supporting balance of their rights. This includes the individual having a choice of food, choice of what to wear in the morning and a choice whether they want to take part in activities or not, along with this, the duty of care will still be delivered along with recognising the individual as an equal partn er, just as any other member of the multi-disciplinary team. The team will also empower the individual to report their changing needs with the integrated care pathway. The team will always support and empower the individual to make the best decision within their medical needs to ensure best care and best treatment plan is taken.

HNC Healthcare Practise Leah Bradley Within health and social care settings record keeping is used to ensure that are providers within health and social care settings can keep on top of what kind of care the patient needs/is given along with when and what time. This can be done in all sorts of ways, for example, when an individual is given medication within a care home, care workers within that setting, must record when, what time and what kind of medication the individual had been given. This would be recorded on the individual’s chart/files which is confidential and can only be access by the individual’s nurse/doctor. This kind of information is recorded to ensure that the other can workers within this setting doesn’t try and give the patient medication again which can cause an overdose, which may leave the individual very ill and can cause death depending on the strength/dosage of the medication. The kind of medication that has been administered into the patient alon g with what dosage and time it was administered will be recorded as well as a signature from the nurse/doctor to authorise it. When recording different types of record keeping, it can be recorded on a confidential database online which would be password protected and only allowed access by the individuals service provider or it can also be handwritten but will also be locked away in filling cabinet. The statutory and regulatory requirements on record keeping involve the care provider ensuring a record is being kept of the care and treatment being provided to each service user. The records are used to plan and describe the care and treatments for the individual in line with their needs, it is important that the record is always kept up to date and that the recording is carried out promptly along with ensuring it is accurate and factual. The service provider that’s recording must always keep the individual’s dignity in mind along with their confidentiality. For example if this setting was within a care home, the RQIA will be the inspecting body requirements, therefore they will want to analyse and evaluate all the paper work to ensure that the record keeping is done correctly, if not done correctly, the RQIA will give them a warning along with changes th at must be made immediately and will reschedule another visit, they may get one more warning for the changes to be made and reschedule another visit. If the changes has still not been made, the care home will be shut down as it is putting the services users at risk if the record keeping isn’t done correctly, for example, if a service provider wasn’t recording the service users medication properly, such as the wrong name or not writing the name of medication or dosage, this could put the individual at risk of getting given more medication if another practitioner wasn’t aware that it already has been given/administered. This can be fatal for some individuals due to the dosage given and what kind of medication it was. Non-compliance is whenever id individual refuses to act upon a request or command. Within health and social care, it can also usually refer to when the patient fails to follow policies and guidelines that had been arranged with the provider within this setting, but it can also refer to when the provider within this setting fails to act accordingly to the guidelines within the health and social care setting. An example of statutory setting with be NHS. This is when a place/setting is funded by the government. This can affect non-compliant regarding record keeping in a very negative way. When this happens, the individual within this setting is not fulfilling their roles within this setting and can lead to complications with patients. For example, if an individual Is given medication within this setting and it is not recorded, this would be non-compliant as they are not following the policies and guidelines within this setting as the information about the medication wasn’t recorded such as the type of medication, the amount, the time administered and who administered/given out this medication. This could result in the individual having an

HNC Healthcare Practise Leah Bradley overdose as they could be given the medication again which could result in the individual becoming ill and possibly needing hospitalized. Non-compliance is whenever id individual refuses to act upon a request or command. Within health and social care, it can also usually refer to when the patient fails to follow policies and guidelines that had been arranged with the provider w ithin this setting but it can also refer to when the provider within this setting fails to act accordingly to the guidelines within the health and social care setting. An example of statutory setting with be NHS. This is when a place/setting is funded by the government. This can affect non -compliant regarding record keeping in a very negative way. When this happens, the individual within this setting is not fulfilling their roles within this setting and can lead to complications with patients. For example, if an individual Is given medication within this setting and it is not recorded, this would be non-compliant as they are not following the policies and guidelines within this setting as the information about the medication wasn’t recorded such as the type of medication, the amount, the time administered and who administered/given out this medication. This could result in the individual having an overdose as they could be given the medication again which could result in the individual becoming ill and possibly needing hospitalized. Legal implications of non-compliance with the GDPR, involving the media, therefore it’s a data breach. This is an organisation who fail to comply and/or suffer a data breach can face a fine depending on how serious the data breach is. In more serious cases this time could be up to 17 million euros or 4% of the company’s annual turnover. This limit can exceed the current maximum fine of £500,000 allowed under the GDPR. (Wright, 2021). This regulation has been included into all local privacy laws throughout the EU and EEA. It will apply to all companies selling to European citizens and holding personal data about them, including companies on other continents. GDPR implies that EU and EEA citizens now have more control over their personal data, as well as reassurance that their data is safely secured across Europe. Personal data is defined as any information about a person, such as a name, a photo, an email address, bank details, updates on social networking websites, geographical details, medical information, or a computer IP address, according to the GDPR law. Records within health and social care settings should always be confidential and only accessed by the individuals service provider, for example, their doctor/nurse. These records can either be files, paperwork, charts. There is range of different types of recording keeping. It can also be stored away on an online database. This database can only be access by the individuals doctor/nurse/service provider and must be always kept confidential, this is the same for paper records, it will be locked away in a filing cabinet and only accessed by the individuals doctor/nurse/service provider. The only way confidentiality can be broke is whenever the information has put the individual at risk of harming themselves or others. This can be known as a need-to-know-basis. There is another way that confidentiality can be broken, this is when an individual involves person centred care therefore involves multi -disciplinary care so the individual’s files/records/charts has to be shared with the other medical professionals. It is important that the NMC implies record keeping when working within their health and social care, whether that may be within the hospital, GP practise or in the community such as a community carer. It is important that record keeping is always

HNC Healthcare Practise Leah Bradley done when working with NMC as it can impact an individual’s life massively, for example, if an individual is given medication either within a hospital or by a nurse at home and it has not been recorded, they have no proof that this individual has been given the medication therefore puts them at risk of getting the medication given to them again which can cause the individual serious complications depending on the dosage and amount of medication given, therefore due to this, this can come across as non-compliant as the individual that gave the medication did not record that the medication had been administered/given to meaning that they did not follow the code/guidelines lay out by the NMC. Information can be shared with internal bodies if the individuals care involves multi disciplinary care. Due to this, the individual’s files and records will have to be shared to others within the team such as the doctor, nurse, physiotherapist, and the social worker so the social worker can make adjustments for this individual. The individual’s files can be shared with external bodies, for example, if the individual passes away, the family may want to see their medical records therefore they have to be shared. Another example of external bodies is the RQIA. If the RQIA comes and makes a visit to the health and social care setting, they may request to see specific files to ensure that they are following the codes, guidelines and policies that are in place when it comes to record keeping. This way the RQIA can then let the setting know if they are doing the record keeping correctly or they may leave notes for changes to be made when this is done. The process that is in place for record keeping is currently very secure and confidential. No other individuals have any way of accessing the other individual’s files due to them being on a secure data base and having a locked filing cabinet for the paper records. I would suggest ensuring that they keys are kept locked away else where when storing them in a filing cabinet or finding a specific locked room to store these records just in case anyone was to ever break up the filing cabinet. I suggest that it should also be a keypad either on the door where they are stored or on the filing cabinet. This way it reduces the risk of they key ever getting stolen or lost. For the database that records are stored on, it can be a bit risky having them saved on there due to potential privacy and security issues. There will always be a chance that the computer can be hacked, and records stolen. There is also a chance that an individual could forget the password to this database which can cause service provider to end up locked out of their patients’ files, leaving them with no other way to access them. I suggest ensuring that the computer they are stored on has a high protection to ensure that it isn’t easy for it to be hacked or for viruses to get into it. Within this care home, all medical files are kept in a computer database but also works with paper records. The information, files, charts, all the record keeping information is initially recorded on to paper then is uploaded online, therefore it is easier to understand online. The paperwork is kept in a locked filing cabinet as a backup just to ensure the patient information will still be there in case anything happens the online database. A model of reflection is the Gibbs model. Gibbs is a six-step action plan, Description, Feelings, Evaluation, Analysis, Conclusion and Action plan. There are advantages and disadvantages to this. The advantages would be, Easy to understand, Allows to learn over time and It gives more balanced and accurate judgement. The disadvantages of this would be, not all practitioners understand this reflective process, May feel uncomfortable challenging and evaluating own practise and Could be time consuming. It is important that practitioners within health and social care

HNC Healthcare Practise Leah Bradley settings try this model to reflect on a situation, whether it was a bad one or one the individual thinks they could’ve done better in, an example of this could be, a practitioner goes to talk to a services users family to give had news and gets upset themselves, the practitioner is extremely disappointed in themselves as the family are the ones that will need the support, this cycle can be used for the practitioner to describe what happened, the feelings/emotions, evaluation of the situation, analyse the outcome, the conclusion of the situation then action plan, what can be done next time to prevent this from happening. If this cycle doesn’t work for some, there is also Rolfes cycle. There is three stages to this cycle, stage 1 “What?”, stage 2 “So what?”, how/what did you learn, and stage 3 “Now what?”, how will I think/act different in the future. Advantages, may be easier to understand, could be easier for the practitioner to use and see where went wrong or what could have improved. Disadvantages of this would be, may have confusion as to which situation/experiences to reflect upon , may not be adequate to resolved certain/specific problems and not all practitioners may understand how to use this model efficiently. Practitioners should use tools to help reflect. These tools could include diaries, journals, personal portfolios. It cou ld also include mind maps, spider diagrams, bullet points. The practitioner should try aa few and use whatever they think suits them to help reflect.

HNC Healthcare Practise Leah Bradley

References Northern Health and Social Care Trust. 2021. Health and social care in Northern Ireland - Northern Health and Social Care Trust. [online] Available at: [Accessed 6 December 2021].